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Based on observation and interview with staff, the facility failed to provide corridors separated by use areas by walls with at least one-half hour fire resistance rating. Findings:

1) Section 19.3.6.2.1, Exception No. 1 reads "in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke." The suspended acoustical ceiling was found to have damaged tiles at various locations in the facility, thus rendering it unable to limit the transfer of smoke at those locations.

2) There is no ceiling in the Water Heater Closet adjacent to the Lab.

3) Section 19.3.6.1 reads "corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5." Physical Therapy is open to the egress corridor in violation of this Section.

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed, and failed to provide no impediment to the closing of the doors. Findings:

1) There is no latching hardware on the door into Soiled Utility, adjacent to Patient Room 8.

2) There is no door closer at the Dishwash Room, opening into the Corridor.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a one half hour fire resistance rating. Findings:

1) Open penetrations were found in the smoke compartment wall (smoke barrier).

Based on observation and interview with staff, the facility failed to provide exit and directional signs that are displayed in accordance with 19.2.10.1. Findings:

1) An exit sign is required leading through the existing door adjacent to the Lab.

Based on observation and interview with staff the facility failed to provide an automatic sprinkler system installed in accordance with NFPA 13. Findings:

1) There is no sprinkler head located in the Heater Room located near the Lab.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 19.5.2.1 and 9.2. Findings:

1) There is no exhaust in the Janitor Closet in the Emergency Department, in Soiled Utility adjacent to Patient Room 8, nor in the Janitor Closet between Patient Rooms 6 and 8.

Based on observation and interview with staff, the facility failed to provide generator recordkeeping. Findings:

1) There is no documentation of an annual inspection and testing of the generator. Refer to NFPA 110 Section 8.4.

Based on observation and interview with staff, the facility failed to provide a Type 1 EES (Essential Electrical System) in accordance with NFPA 99 - 1999 Edition. Findings:

1) The facility failed to provide a Type 1 EES comprised of two separate systems; the Emergency System and the Equipment System. The Emergency System shall be divided into two Life Safety Branch and the Critical Branch, and shall supply power to those items and areas identified in 3-4.2.2.2 (b) and (c). The Equipment Branch shall supply power as identified in 3-4.2.2.3.

2) Each branch of the emergency system and each equipment system shall have one or more transfer switches. Only one transfer switch was found for the 218 kva generator.

Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70 and NFPA 99. Findings:

1) Open junction boxes were found in various locations above the ceiling in the facility.

2) Two pieces of electrical equipment were found in the kitchen to be wired with orange extension cords and plugged into wall receptacles.
3) An emergency wall mounted light pack was found to be plugged into a wall receptacle, located between Patient Rooms 5 and 7.

Based on observation and interview with staff, the facility failed to provide corridors separated by use areas by walls with at least one-half hour fire resistance rating. Findings:

1) Section 19.3.6.2.1, Exception No. 1 reads "in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke." The suspended acoustical ceiling was found to have damaged tiles at various locations in the facility, thus rendering it unable to limit the transfer of smoke at those locations.

2) There is no ceiling in the Water Heater Closet adjacent to the Lab.

3) Section 19.3.6.1 reads "corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5." Physical Therapy is open to the egress corridor in violation of this Section.

Based on observation and interview with staff, the facility failed to provide doors with a means suitable for keeping the door closed, and failed to provide no impediment to the closing of the doors. Findings:

1) There is no latching hardware on the door into Soiled Utility, adjacent to Patient Room 8.

2) There is no door closer at the Dishwash Room, opening into the Corridor.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a one half hour fire resistance rating. Findings:

1) Open penetrations were found in the smoke compartment wall (smoke barrier).

Based on observation and interview with staff, the facility failed to provide exit and directional signs that are displayed in accordance with 19.2.10.1. Findings:

1) An exit sign is required leading through the existing door adjacent to the Lab.

Based on observation and interview with staff the facility failed to provide an automatic sprinkler system installed in accordance with NFPA 13. Findings:

1) There is no sprinkler head located in the Heater Room located near the Lab.

Based on observation and interview with staff, the facility failed to provide HVAC complying with 19.5.2.1 and 9.2. Findings:

1) There is no exhaust in the Janitor Closet in the Emergency Department, in Soiled Utility adjacent to Patient Room 8, nor in the Janitor Closet between Patient Rooms 6 and 8.

Based on observation and interview with staff, the facility failed to provide generator recordkeeping. Findings:

1) There is no documentation of an annual inspection and testing of the generator. Refer to NFPA 110 Section 8.4.

Based on observation and interview with staff, the facility failed to provide a Type 1 EES (Essential Electrical System) in accordance with NFPA 99 - 1999 Edition. Findings:

1) The facility failed to provide a Type 1 EES comprised of two separate systems; the Emergency System and the Equipment System. The Emergency System shall be divided into two Life Safety Branch and the Critical Branch, and shall supply power to those items and areas identified in 3-4.2.2.2 (b) and (c). The Equipment Branch shall supply power as identified in 3-4.2.2.3.

2) Each branch of the emergency system and each equipment system shall have one or more transfer switches. Only one transfer switch was found for the 218 kva generator.

Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70 and NFPA 99. Findings:

1) Open junction boxes were found in various locations above the ceiling in the facility.

2) Two pieces of electrical equipment were found in the kitchen to be wired with orange extension cords and plugged into wall receptacles.
3) An emergency wall mounted light pack was found to be plugged into a wall receptacle, located between Patient Rooms 5 and 7.